Provider Demographics
NPI:1396868691
Name:BURNHAM, JON (LCSW)
Entity type:Individual
Prefix:MR
First Name:JON
Middle Name:
Last Name:BURNHAM
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 S AUSTIN AVE
Mailing Address - Street 2:
Mailing Address - City:SUGAR CITY
Mailing Address - State:ID
Mailing Address - Zip Code:83448-5078
Mailing Address - Country:US
Mailing Address - Phone:208-201-1300
Mailing Address - Fax:
Practice Address - Street 1:2691 S 2000 W
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-4049
Practice Address - Country:US
Practice Address - Phone:208-701-9616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-276071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical